The Clinical Efficacy and Safety of Ertapenem for the Treatment of Complicated Urinary Tract Infections Caused by ESBL-Producing Bacteria in Children

Hidradenitis Suppurativa in Children and Adolescents: An Update on Pharmacologic Treatment Options

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin condition that manifests as painful, deep-seated, inflamed nodules and abscesses in the axillary, groin, perianal, perineal, and inframammary regions. The associated pain, malodour, and disfigurement contribute to its profound negative impact on psychosocial spheres and overall quality of life in affected individuals. Although the symptoms of HS classically begin in the second or third decade of life, HS affects children and adolescents as well. Despite this, there are limited pediatric data on treatment, which are largely based on expert opinion, extrapolation of efficacy data in adults with HS, and safety information from medication use in other pediatric diseases. On this basis, there exist several pharmacological modalities in the treatment of children and adolescents with HS including topical therapies, systemic therapies, and biologics. The goals of this review article are to: (1) review the efficacy of different pharmacological treatment modalities in children and adolescents with HS, and (2) review the safety and monitoring considerations of the different treatment options in children and adolescents with HS.

Effectiveness of ertapenem for treatment of infections in children: An evidence mapping and meta-analysis

OBJECTIVES

To assess and summarize current evidence on the effectiveness and safety of ertapenem for treatment of childhood infections, in consideration of high infection prevalence in children and wide use of ertapenem.

METHODS

The following 8 databases were searched on 13th May 2021: Web of Science, Embase via Ovid SP, PubMed, The Cochrane Library (CENTRAL), Chinese BioMedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), VIP and Wanfang. The primary outcome was treatment success rate. Risk ratios (RRs) and 95% confidence interval (CI) were estimated using random-effect models. Subgroup analysis was conducted where heterogeneity was found.

RESULTS

Fifteen studies (8 randomized controlled trials, 1 observational comparative study, and 6 before and after studies) involving 2,528 patients were included in the final review. Ertapenem had similar treatment success rates with β-lactam antibiotics [relative risk (RR) = 1.08, 95% CI: 0.99-1.19]. In a subgroup analysis, similar efficacy (RR = 1.08, 95% CI: 0.97-1.20) between ertapenem and other carbapenems. Compared with β-lactam antibiotics, ertapenem did not increase the risk of any adverse events (RR = 1.02, 95%CI: 0.71-1.48), drug-related diarrhea (all non-Asian children, RR = 0.62, 95%CI: 0.31-1.25), or injection site pain (all non-Asian children, RR = 1.66, 95%CI: 0.59-4.68). Subgroup analysis showed no obvious difference between ertapenem group and carbapenems or non-carbapenems group on risk of adverse events.

CONCLUSION

Our findings suggest that ertapenem is effective and safe in treatment for children with infection. Further comparative real-world data is needed to supplement clinical evidence on the overall benefits of ertapenem in this population.

Antibiotic Resistance in Paediatric Febrile Urinary Tract Infections

Febrile urinary tract infection (UTI) is currently considered the most frequent cause of serious bacterial illness in children in the first 2 years of life. UTI in paediatrics can irreversibly damage the renal parenchyma and lead to chronic renal insufficiency and related problems. To avoid this risk, an early effective antibiotic treatment is essential. Moreover, prompt treatment is mandatory to improve the clinical condition of the patient, prevent bacteraemia, and avoid the risk of bacterial localization in other body sites. However, antibiotic resistance for UTI-related bacterial pathogens continuously increases, making recommendations rapidly outdated and the definition of the best empiric antibiotic therapy more difficult. Variation in pathogen susceptibility to antibiotics is essential for the choice of an effective therapy. Moreover, proper identification of cases at increased risk of difficult-to-treat UTIs can reduce the risk of ineffective therapy. In this review, the problem of emerging antibiotic resistance among pathogens associated with the development of paediatric febrile UTIs and the best potential solutions to ensure the most effective therapy are discussed. Literature analysis showed that the emergence of antibiotic resistance is an unavoidable phenomenon closely correlated with the use of antibiotics themselves. To limit the emergence of resistance, every effort to reduce and rationalise antibiotic consumption must be made. An increased use of antibiotic stewardship can be greatly effective in this regard.

Daily inpatient ertapenem therapy can be an alternative to hospitalization for the treatment of complicated urinary tract infections during the COVID-19 pandemic

BACKGROUND

Physicians hospitalize the patients with complicated urinary tract infections (cUTIs) when they need intravenous antibiotics and outpatient parenteral antimicrobial therapy (OPAT) is unavailable. Daily inpatient antimicrobial therapy is an alternative to hospitalization, which is similar to OPAT; patients go home after they are administered antibiotics in a separate room in the hospital setting.

OBJECTIVES

We assessed our previous daily inpatient practice to revitalize the model in the COVID-19 era.

MATERIALS AND METHODS

We retrospectively evaluated the clinical and microbiological responses and the cost effectiveness of the patients with cUTIs who received daily inpatient ertapenem therapy.

RESULTS

Our study population was 136 patients in 156 episodes. It was a difficult-to-treat group with older age (mean 63.0 ± 14.8 years) and a high burden of underlying conditions (86.5%). The most common causative organisms were Escherichia coli (74.4%) and Klebsiella pneumoniae (19.2%); 89.7% of the isolates were producing extended-spectrum beta lactamase (ESBL). The microbiologic and clinical success rates were 82.1% and 95.5%, respectively. The patients required hospitalization in 16 episodes (10.2%) because of clinical failures (3.8%), superinfections (2%), planned invasive interventions (3.2%), and side effects (1.2%). Our university hospital saved 1608 bed-days and 2596 € (9702 TL) bed costs.

CONCLUSIONS

In the COVID-19 pandemic period, this seems to be an effective, safe, and cost-effective way to decrease hospitalizations for cUTIs in settings where OPAT is unavailable.

Recent molecules in the treatment of severe infections caused by ESBL-producing bacteria

Introduction: The widespread increase in resistance to β-lactam antibiotics in Enterobacterales currently represents one of the main threats to human health worldwide. The primary mechanisms of resistance are the production of β-lactamase enzymes that are able to hydrolyze β-lactams.Areas covered: we summarize the most recent advances regarding the main characteristics and spectrum of activity of new available antibiotics and strategies for the treatment of ESBL-producing Enterobacterales infections.Expert opinion: ESBL-producing strains are recognized as a worldwide challenge in the treatment of both hospital- and community-acquired infections. Data from the literature point out the high mortality associated with severe infections due to ESBL strains, especially in patients who developed severe sepsis or septic shock, together with the importance of the source of infection and indicators of severity, as determinants of the patient's outcome. Carbapenems are currently considered the first-line therapy, although the diffusion of resistant strains is an evolving problem and is mandatory the introduction in clinical practice of new drug regimens and treatment strategies, based on clinical data, local epidemiology, and microbiology. As a possible carbapenem-sparing strategy, ceftolozane-tazobactam and ceftazidime-avibactam appear the best-available carbapenem-sparing therapies. The definitive role of new drugs should be definitively assessed.

Multidrug-resistant organisms in urinary tract infections in children

The global spread of multidrug-resistant organisms has led to an increase in urinary tract infections (UTIs) in children that are difficult to treat. This review explores the current literature regarding multidrug-resistant UTIs in childhood and proposes an approach to management. Multidrug-resistant organisms include a wide range of potential urinary tract pathogens and, while most literature on drug resistance in UTIs during childhood has focused on extended-spectrum beta-lactamase producing organisms, in this review, we have included a discussion of multidrug resistance including and beyond beta-lactamase production. We provide definitions for multidrug-resistant organisms in line with current consensus guidelines and summarise clinically relevant mechanisms of resistance. Additionally, in this review, we outline the global epidemiology of multidrug-resistant UTIs in children, summarising published prevalence rates, which range from 5 to 90% in different settings. Finally, we also critically review the evidence on risk factors for colonisation and infection of the urinary tract with multidrug-resistant organisms, including prior antibiotic use, hospitalisation and underlying urological malformations. We also highlight multidrug-resistant UTI occurring in children without any identifiable risk factors, reflecting an increasing prevalence of colonisation with these organisms in the general community. Taken as a whole, this emphasises a need for careful and evidence-based use of antibiotics when treating UTIs in children and, to aide clinicians, we have outlined here potential management strategies for when infection with a multidrug-resistant organism is suspected or confirmed.

Treatment of Infections Caused by Extended-Spectrum-Beta-Lactamase-, AmpC-, and Carbapenemase-Producing Enterobacteriaceae

Therapy of invasive infections due to multidrug-resistant Enterobacteriaceae (MDR-E) is challenging, and some of the few active drugs are not available in many countries. For extended-spectrum β-lactamase and AmpC producers, carbapenems are the drugs of choice, but alternatives are needed because the rate of carbapenem resistance is rising. Potential active drugs include classic and newer β-lactam-β-lactamase inhibitor combinations, cephamycins, temocillin, aminoglycosides, tigecycline, fosfomycin, and, rarely, fluoroquinolones or trimethoprim-sulfamethoxazole. These drugs might be considered in some specific situations. AmpC producers are resistant to cephamycins, but cefepime is an option. In the case of carbapenemase-producing Enterobacteriaceae (CPE), only some "second-line" drugs, such as polymyxins, tigecycline, aminoglycosides, and fosfomycin, may be active; double carbapenems can also be considered in specific situations. Combination therapy is associated with better outcomes for high-risk patients, such as those in septic shock or with pneumonia. Ceftazidime-avibactam was recently approved and is active against KPC and OXA-48 producers; the available experience is scarce but promising, although development of resistance is a concern. New drugs active against some CPE isolates are in different stages of development, including meropenem-vaborbactam, imipenem-relebactam, plazomicin, cefiderocol, eravacycline, and aztreonam-avibactam. Overall, therapy of MDR-E infection must be individualized according to the susceptibility profile, type, and severity of infection and the features of the patient.